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Royal College of Psychiatrists Consultation Response
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DATE: |
23 June 2017
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RESPONSE OF: |
THE ROYAL COLLEGE OF PSYCHIATRISTS in WALES
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RESPONSE TO: |
ELGC Committee, Poverty Making the economy work for people on low incomes
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The Royal College of Psychiatrists is the professional medical body responsible for supporting psychiatrists throughout their careers, from training through to retirement, and in setting and raising standards of psychiatry in the United Kingdom.
The College aims to improve the outcomes of people with mental illness, and the mental health of individuals, their families and communities. In order to achieve this, the College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers and their organisations. Nationally and internationally, the College has a vital role in representing the expertise of the psychiatric profession to governments and other agencies.
RCPsych in Wales is an arm of the Central College, representing over 550 Consultant and Trainee Psychiatrists working in Wales.
1. The College is pleased to respond to the Equality, Local Government and Communities Committee inquiry into Poverty: Making the economy work for people on low incomes. Martin Lewis, founder of Moneysavingexpert.com wrote, “Sadly financial problems and mental health are a marriage made in hell.”[1] This statement may appear alarming but it is no surprise to those working in primary and secondary care mental health services or those living with a mental health condition and their loved ones, who experience first-hand the impact that this complex relationship has on individuals, their families and their communities.
2. There is extensive evidence that confirms this link:
· Around half of all people with debts have a mental health condition, compared with only 14% of the population without debts.[2] People with a mental health condition are roughly three times more likely to be in debt, and the more debts people have the more likely they are to have some form of mental illness.[3]
· People on lower incomes are more likely to experience poor mental health than those on higher incomes. The correlation between poverty and mental health is also evident: only 43% of all people with mental health conditions are in employment, compared to 74% of the general population and 65% of people with other health conditions.[4]
· Countries with greater disparity between the rich and the poor have a higher prevalence of mental health conditions in the general population, especially depression and anxiety disorders (see Graph 1).
Graph 1: Income Inequality and Mental Health Conditions[5]
3. It is important to understand that people with mental illness are at greater risk of being socially excluded from participation in many areas of society and these include: 1, from material resources (low or no income and more debt); 2, from productive activity (low levels of education); 3, from social relations and neighbourhoods (low access to community facilities); 4, from civic participation (in local and national decision making); and 5, from health and health services (increased risk of premature death).[6] All of these factors are particularly relevant for people with severe mental illness and for people with learning disabilities.
4. Children of parents with poor mental health are also affected by poverty. Public Health Wales reports[7] on the effects of adversity on children in their development into adulthood and a number of factors, including household mental illness, increases their chances of adopting health-harming behaviours and poor mental health across the life course. Although the report does not recognise poverty specifically, all adverse events listed in the report are closely linked with poorer incomes and deprived areas.
Mental Health and employment
5. In the RCPsych response to the Green Paper, Health, Work and Disability (February 2017) we write that, in general, it is good for people to be employed, “…however, jobs with poor psychosocial quality can be as bad for a person’s mental health as unemployment. Poor quality jobs include those with high job demands and complexity, low job control, job insecurity and unfair pay.” We continue to write, “There is also a need to recognise that poor health and poor work outcomes are also determined by other social disadvantages. Many people with mental health problems tell us that good and appropriate work can be good for their mental health – this message may be more appropriate.”[8] Again, all of these factors are particularly relevant to people with serious mental illness and those with learning disabilities.
6. Poverty often leads to poor mental health.[9] The poor are often exposed to dangerous environments, who (if in work) have stressful or unrewarding jobs, and who are often isolated because they are not part of mainstream society[10]. Poverty can also be a consequence of mental health, as well as a determinant.[11] It is more difficult for someone with a mental illness to study or hold down a job as they may require intermittent and/or frequent time off for treatment. There is also a stigma attached to mental illness, as often with a physical illness, where employers may perceive the individual to be unreliable or at higher risk when working whilst unwell.
7. It is therefore not surprising that many people with a mental illness who are in employment, may feel unsupported and isolated, often worried about the implications their illness will have on their employability and their relationships with others. Employers must be able to provide support for people with mental health conditions. The Equalities Act (2010) protects people from discrimination in the workplace and requires employers to make reasonable adjustments for people with disabilities. Anecdotal evidence from our members suggests that employers are unclear what these adjustments look like for people with mental health conditions.
8. Recommendation: We believe that more work should be done with employers to ensure they are aware of the support they should be offering people with mental health issues and how they can create workplaces that are compassionate and understanding for those living with mental health conditions, as they would for staff with physical conditions. Businesses must act ethically.
Barriers to employment
9. People with disabilities are more than twice as likely as non-disabled people to be without work.[12] Welsh Government policy should be encouraging people to work by using its powers to shape the labour market, attracting the right jobs in Wales, because ‘good and appropriate work’ can be good for one’s mental health.
10. Individual Placement and Support is an evidence-based approach to supporting people with serious mental illness to gain meaningful and competitive employment. IPS focuses on rapid placement in work and on-going support after placement (‘place-and-train’). This differs to the traditional ‘train-and-place’ models which focus on a prolonged period of assessment and preparatory training. It is based on eight principles:
Table 1: The 8 Principles of the Individual Placement and Support Approach[13]
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1 |
Every person with severe mental illness who wants to work is eligible for IPS supported employment. |
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Employment services are integrated with mental health treatment services. |
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Competitive employment is the goal. |
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Personalized benefits counseling is provided. |
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The job search starts soon after a person expresses interest in working. |
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Employment specialists systematically develop relationships with employers based upon their client's preferences. |
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7 |
Job supports are continuous. |
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8 |
Client preferences are honored. |
11. Recommendation: The College recommends that the Welsh Government adopt the principles of Individual Placement and Support. Welsh Government’s attempt to get people into work may be modelled on the principles of IPS, which are person-centred.
12. Recommendation: As IPS is usually delivered by supported employment teams that operate within Community mental Health Teams (CMHTs). We recommend that IPS is developed in all Health Boards across Wales.
Problems with benefits
13. Doctors and disability rights organisations have raised concerns that the Work Capability Assessment has had an adverse effect on the mental health of claimants.[14] [15] The programme of reassessing people on disability benefits using the Work Capability Assessment was independently associated with an increase in suicides, self-reported mental health conditions and antidepressant prescribing.[16] This policy may have resulted in serious adverse consequences for mental health, which could outweigh any benefits that arise from moving people off disability benefits.
14. Mental Health professions in the UK spend most of their time treating people with lifelong experience of poverty.[17] Very often they are asked to provide clinical evidence to support a patient’s claim for benefits and on occasion perform a face-to-face assessment. There have been concerns raised by patients about the disparity in level of cooperation from clinicians and there are concerns from professionals who are unaware of training or guidance in this area. The College has published guidance, and specifies in our Guidance for Mental Health Clinicians providing Clinical Evidence for the Work Capability Assessment (WCA)[18] the importance of good quality written evidence which is clear and accurate, and focuses on the type of information needed to assess a person’s capability for work. Robert Poole, et.al. writes that “Clinicians have to be open to learning about the lifestyle and culture of people who may be living very different lives to themselves”.[19]
15. The RCPsych Central response to the Work, Health and Disability Green Paper states, “We acknowledge how anxiety-inducing the process of completing detailed forms and gathering medical evidence is for people with mental health problems. We support eliminating the duplication of processes and energy, which would make this process easier to navigate. Any system that allows people to share data between assessments needs the full consent of individuals and their complete control about what and how information is shared.” [20]
16. Specialist advice on benefits for people with severe mental illness would reduce costs on secondary care services.[21] More research is needed to establish the frequency with which specialist advice services can provide favourable outcomes and cost savings. Evidence shows that only a small number of successful interventions are needed for an advice service to generate sufficient savings to be good value for money - this is because the costs of severe mental illness are so high relative to the costs of the advice. We are concerned that austerity has resulted in cuts to funding in this area in particular.
17. Recommendation: Training must be available forprofessionals in helping patients with WCA and PIP. Where possible, a benefit support worker should work within mental health services. The Health Boards should publicise widely the College’s Guidance for Mental Health Clinicians providing Clinical Evidence for the Work Capability Assessment (WCA)
18. Recommendation: Welsh Government must consider developing specialist financial advice services for people with mental health conditions. The level of funding has been reduced although supporting these services would result in cost savings and better patient outcomes.
We need to develop a system of social security whereby people can receive out of work benefits when they fall ill and are unable to work, and disability benefits for those with long-term disabilities. This system needs to be supported by other opportunities to receive payments and exemptions to cover other essential living costs, such as housing. The assessment systems for these payments should be accurate, effective and fair to ensure that people who are eligible for benefits receive them on time and have access to a fair appeals process. The payments and exemptions should be sufficient to enable people to live above the poverty threshold. These principles acknowledge the historical experiences of many people with disabilities, including those with mental health conditions, who have lived in poverty and the current excess of people with disabilities who live in low income households
RCPsych response to Work, Health and Disability Green Paper p3.
References:
All Party Parliamentary Group on Disability, 2016
Barr, B. et. al. ‘First, do no harm’: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study, J Epidemiol Community Health 2015;0:1–7
Boardman, J. Social exclusion and mental health – how people with mental health problems are disadvantaged: an overview, Mental Health and Social Inclusion, VOL. 15 NO. 3 2011, pp. 112-121
Hale, C. (2017) Fulfilling Potential: ESA and the fate of the Work-Related Activity Group, Mind and the Centre for Welfare Reform.
Jenkins, R. et. al. (2009) Mental disorder in people with debt in the general population. Public Health Medicine. 6(3), 88-92.
Langner, T. S. & Michael, S. T. (1963) Life Stress and Mental Health. London: Collier-Macmillan.
Murali, V et.al. Poverty, social inequality and mental health, Advances in Psychiatric Treatment May 2004, 10 (3) 216-224; DOI: 10.1192/apt.10.3.216
Parsonage. M., (2013) Welfare advice for people who use mental health services, Centre for Mental Health.
Pickett KE, Wilkinson RG. Inequality: an underacknowledged source of mental illness and distress. Br J Psychiatry 2010 ; 197: 426– 8
Poole, R. et.al. (2014) Mental Health and Poverty, Cambridge University Press.:p118.
Public Health Wales (2016) Adverse Childhood Experiences and their association with chronic disease and health service use in the Welsh adult population, PHW.
RCPsych (February 2017) Response to the Health, Work, and Disability Green Paper. http://www.rcpsych.ac.uk/pdf/RCPsych%20response%20to%20Work,%20Health%20and%20Disability%20Green%20Paper.pdf
Walker, R. et. al. Poverty in Global Perspective: Is Shame a Common Denominator? Jnl Soc. Pol. (2013), 42, 2, 215–233 C _ Cambridge University Press 2013